Provider Demographics
NPI:1114083367
Name:TRI COUNTY EYE ASSOCIATES PA
Entity Type:Organization
Organization Name:TRI COUNTY EYE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-797-5760
Mailing Address - Street 1:25 DELTONA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4204
Mailing Address - Country:US
Mailing Address - Phone:904-797-5760
Mailing Address - Fax:904-797-5762
Practice Address - Street 1:25 DELTONA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4204
Practice Address - Country:US
Practice Address - Phone:904-797-5760
Practice Address - Fax:904-797-5762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0911760003Medicare NSC